Below, you’ll find our most-requested patient forms at Southeastern Spine · Brain · Joint. Please print and fill out the forms that apply to your situation before your first visit at Southeastern Spine · Brain · Joint.
Please bring the following when you visit Southeastern Spine · Brain · Joint for your first appointment:
- Completed New Patient Information Form and additional paperwork from the list below
- New Patient Information Form – Dr. Bernard
- New Patient Information Form – Lumbar Spine
- New Patient Information Form – Cervical Spine
- Your Insurance Card
- Co-payment (if required by insurance). We accept cash, major credit cards or personal check.
- Referral paperwork (if required by your insurance).
- Medical records and imaging reports, x-rays, and/or disc with imaging pertaining to your treatment from other health care providers (if you have them).
New Patient Filing Workers Comp or Auto Accident Forms:
- Injury Patient Information Form
- Auto Accident Attorney Letter of Protection
- Personal Injury Insurance Filing Selection Notice
Please review these important notices:
- HIPAA Notice – This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Nondiscrimination Statement
Southeastern Spine · Brain · Joint will provide a thorough evaluation based on your symptoms, conditions and medical history. Bringing this information to your first appointment ensures that we can provide the best possible service during your first consultation.